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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400240
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:16:44 PM

Document Has Been Signed on 01/18/2024 01:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JACKSON FAMILY CHILD CAREFACILITY NUMBER:
198400240
ADMINISTRATOR:SHAWNTAYZIA A. JACKSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 556-3416
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 14TOTAL ENROLLED CHILDREN: 16CENSUS: 5DATE:
01/18/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Shawntayzia Jackson, LicenseeTIME COMPLETED:
01:35 PM
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Licensing Program Analysts (LPA) Susann Sanchez and Anthony Padilla conducted an unannounced annual inspection to the above facility on 01/18/2024. LPA met with Shawntayzia Jackson, Licensees and guided LPAs on a tour of the facility. Per Licensee, operation hours are Monday through Friday from 6AM to 6PM. However, Licensee stated she does extend hours once in a while depending on parents needs. There are 16 children that are currently enrolled according to the roster. There was 4 day-care children and one infant present upon arrival. The licensee provides food for children in care.

All areas identified on the facility sketch were inspected that are used by children. This is a one story home that consists of 3 bedrooms, 2 restrooms, dining area, living room, kitchen, sun- room/ daycare room, garage, backyard, and front yard. Per Licensee, the children will use the restroom in the hallway, dining, sun-room/ day-care room, living room, and front yard. Areas that will be used by children were observed for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible and are kept in a locked cabinet under the kitchen sink. At 10:45, LPAs observed cleaning product (Clorox wipes & hair products) under the bathroom sink. Licensee immediately removed items. A technical violation was given.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption. Licensee states that there are no firearms stored in the home.

All areas identified on the facility sketch that are accessible for children to use were inspected. LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 8/9/23.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Anthony Padilla
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 198400240
VISIT DATE: 01/18/2024
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Smoke and carbon monoxide detector were tested and are operable. At 10:55am, LPAs observed required 2A10BC fire extinguishe fully charged but has not been serviced 10/17/2022. Type B violation was cited. The home maintains telephone service via cell phone. There are age appropriate equipment, toys and material available for children. Isolation area for sick children waiting to be picked up is in the dining area, away from the other children.

Currently facility has infants enrolled and one infant was present. LPA reminded Licensee of the following appropriate sleeping arrangements is needed. Play yards cannot hinder the entrance or exit from the sleeping space. Mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Play yards are to be free of loose articles and objects. LPA discussed new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP.

Currently due to mosquitos in the back yard the children play in the front yard. There are no pools or spas, or other bodies of water. There is one medium dog in the backyard, that is gated and not accessible to children Per licensee dog does not interact with children. Per licensee the back yard will be ready to use in one week. LPAs toured the backyard and saw no concerning issues with the yard.

At 11:50am, LPA reviewed children’s files. Two of the five children present did not have children's records. Type B was cited.

Staff records were reviewed for approved: LIC 508- Criminal Record Statement, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse, Pediatric First Aid and CPR (expires 06/13/25). At 11:30am, Licensee stated that she has renewed her Mandated Reporter Training and expired in 2021.

Licensee was reminded that all adults 18 and over, including employees and volunteers, expect as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be up assessed if this regulation is violated.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Anthony Padilla
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 198400240
VISIT DATE: 01/18/2024
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensee was informed of the MyChildCare.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resources and Referral Agencies (R&Rs) throughout California. To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.


During the exit interview Licensee S. Jackson, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Based on the LPA’s observations, interviews and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety. Deficiencies include two type B violations. An exit interview was conducted, and report was reviewed with Licensee. A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. Appeal rights were discussed and provided to the Licensee.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Anthony Padilla
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/18/2024 01:16 PM - It Cannot Be Edited


Created By: Anthony Padilla On 01/18/2024 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 198400240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPAs observed fire extingusiher was last serviced on 10/17/2022. Licensee stated she didn't realized it wasn't serviced in 2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2024
Plan of Correction
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Per Licensee will get fire extinguisher will be serviced by POC due date of 01/25/24 and will submit photos to LPA via email.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review)], the licensee did not comply with the section cited above. During record review, LPAs did not observe a current Mandated Reporter training. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Per Licensee will submit an updated Mandated Reporter by POC due date 02/02/24 via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Chambers
LICENSING EVALUATOR NAME:Anthony Padilla
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/18/2024 01:16 PM - It Cannot Be Edited


Created By: Anthony Padilla On 01/18/2024 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 198400240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Child #4 & #5 were missing (LIC) 282- Affidavit Regarding Liability Insurance, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights LIC 9227 LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee will submitt a photo by POC due date of 2/02/24 via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Chambers
LICENSING EVALUATOR NAME:Anthony Padilla
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


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